Panel Suggests Osteoporosis Screening at Age 65 For Women

Critics argue this is too little, too late

Starting at age 65, women should be routinely screened for osteoporosis to reduce the risk of bone fractures associated with the disease, says a panel of experts in newly released recommendations.

And women ages 60 to 64 at high risk for the disease should also be screened, the panel says.

New Guidelines Reiterate Previously Made 
Recommendations

The new guidelines are the first made on osteoporosis by the US Preventive Services Task Force, a panel sponsored by the federal Agency for Healthcare Research and Quality. But they mirror recommendations made in the past by such groups as the National Osteoporosis Foundation and the American College of Obstetricians and Gynecologists.

New Recommendations Not Without Criticism

However, the new guidelines, published in a recent edition of the Annals of Internal Medicine, are already being criticized by some osteoporosis experts who say screening at 65—or even 60—is too little, too late. Screening should begin at least 10 years earlier, the critics say.

Osteoporosis, the "fragile bone" disease that results from low bone mineral density, affects about 10 million Americans, including eight million women and two million men, according to estimates from the National Osteoporosis Foundation.

The fractures that result, especially of the hip or spine, can cause costly hospitalization and high convalescent costs. Another 34 million Americans have low bone mass, putting them at higher risk of osteoporosis, says the National Osteoporosis Foundation. Thinner women are also at higher risk of developing the disease than heavier women.

In response to the criticism, those who assembled the new guidelines say the recommendations are based on sound, scientific evidence.

"Fractures in general occur later in life," says Dr. Heidi Nelson, associate professor of medicine and medical informatics and outcome research at the Oregon Health & Science University in Portland. She is the lead author of the evidence review report used by the panel that also appears in the same issue of the Annals of Internal Medicine.

"So focusing on those who have the higher risk of fracture and treating them" is considered the most effective strategy from a public health viewpoint, she says. "These are evidence-based guidelines," she adds. "By starting the screening at age 65, we have the biggest impact."

The recommendation, the panel says, is based not on evidence that screening can reduce fractures associated with osteoporosis but rather on evidence that testing bone density can identify women who could benefit from an array of bone-building medicines now available and perhaps avoid fractures.

"As a task force, we probably are looked upon as conservative," says Janet Allan, the task force vice chair who is dean of the School of Nursing at the University of Maryland in Baltimore.

"Our charge is, we develop guidelines based on evidence," she adds. After evaluating dozens of "high quality" studies, the panel found that the benefit is to screen all women age 65 and older.

The panel did not specify how frequently subsequent screenings should take place after the initial screening.

How Is Bone Mineral Density Measured?

To test bone mineral density, a test called the DEXA (dual-energy x-ray absorptiometry) is considered the gold standard. A person lies on an examining table while the bones are scanned by an x-ray.

Even though the new guidelines are based on scientific evidence, some experts do not agree with them.

"I think they're too late," says Dr. J. Michael Uszler, a nuclear medicine physician at Santa Monica-UCLA Medical Center in Santa Monica, Calif. "The prominent loss of bone density occurs in the first five years after menopause," he says. In the United States, the average age of menopause is about 51 years.

Ideally, Uszler says, a woman should undergo a bone scan "within two years after the end of menopause."

Another critic of the new guidelines is Dr. Robert Heaney, professor of medicine at Creighton University in Omaha, Neb., and a scientist at the university's Osteoporosis Research Center.

"I think they are too conservative, and driven by cost consideration," Heaney says. The cost of a DEXA scan is about $125 to $300, according to Allan. But it can vary considerably.

At Heaney's center, where 12,000 DEXA scans are done each year, the average price per scan is just under $20, including personnel time and equipment use, he says. Testing facilities could charge $40 and "still make a profit," he adds.

"I would recommend that women have access to bone scanning when they are seriously interested in taking a look," Heaney says. For most, that means midlife, from about age 40 to 60, he says.

As Nelson acknowledges, "65 isn't magic. If women younger have a number of risk factors," they should consider a test, too.

Adds Allan, the task force vice chair: "There is always room for individual preference."

Always consult your physician for more information.

Online Resources 

Agency for Healthcare Research and Quality

American College of Obstetricians and Gynecologists

Annals of Internal Medicine

National Osteoporosis Foundation

US Department of Health and Human Services

US Food and Drug Administration (FDA)

US Preventive Services Task Force

October 2002

New Guidelines Reiterate Previously Made Recommendations

New Recommendations Not Without Criticism

How Is Bone Mineral Density Measured?

New Medication Promises to Revolutionize Treatment For Osteoporosis

Online Resources

New Medication Promises to Revolutionize Treatment For Osteoporosis 

For women who suffer from osteoporosis, the news is good: A new medication promises to revolutionize treatment for the bone-thinning disease, particularly in women with the most severe problems.

The drug, a synthetic version of human parathyroid hormone called PTH, works by helping the body build new bone—even after dramatic loss has occurred.

"Unlike other treatments for osteoporosis, which can help stop bone loss, parathyroid hormone actually helps the body build new bone, so that a woman has a chance to put back what her skeleton has lost over time to osteoporosis," says endocrinologist Dr. Loren Wisner Greene, co-director of the Bone Density Center at New York University Medical Center.

Although most of us stop growing in height in our late teens, our skeleton actually remains a work in progress for most of our lives, continually breaking down and re-building bone mass at a fairly steady rate.

When osteoporosis sets in, however, bone loss begins to occur faster than the rebuilding process can take place. And that means instead of being strong and solid, bones become porous, filled with little holes or craters.

As the disease progresses, there is less bone "mass" and more bone "holes"—turning a strong skeleton into one that can be weak and vulnerable.

For women, who comprise the vast majority of osteoporosis patients, the problems generally become extremely apparent after menopause, a time when levels of the hormone estrogen drop dramatically.

Why is this important?

Estrogen helps to regulate factors involved in bone formation, Wisner Greene says. When estrogen levels fall, so does the production of new bone cells, she adds.

For women who start out with less bone mass to begin with, even a tiny loss can spell trouble.

"The end result can be weaker bones, and a dramatically increased risk of fracture, particularly of the hip, spine, and wrist," says Wisner Greene.

Although there are a variety of medications available to treat osteoporosis, they all work in pretty much the same way—to stop the bone loss.

PTH, however, stimulates new bone cell production. The results, according to endocrinologist Dr. John Adams, are nothing short of astounding.

"This drug is remarkable in the fact that while all of the other [osteoporosis] drugs are designed to inhibit bone loss, this is completely different in that it stimulates the bone forming cell, the osteoblast," says Adams, the director of the endocrinology, diabetes and metabolism division at Cedars-Sinai Medical Center in Los Angeles.

When combined with drugs that stop bone loss, like Fosamax (aldendronate), parathyroid hormone becomes the ultimate way to increase skeletal strength, Adams says.

"I'm planning on putting every single one of my patients on this medicine as soon as it becomes available. I feel that strongly about it," says Adams.

As good as it sounds, there are some caveats to consider. First, the drug must be injected daily, which could be problematic for some women.

More important, however, while human trials as long as 20 months showed no serious side effects, a study involving rats found parathyroid hormone has the potential for causing an extremely rare but life-threatening form of bone cancer.

Although the rats received doses far above the human equivalent and were treated with the drug for an entire lifetime, the US Food and Drug Administration (FDA) was concerned enough to request that the manufacturer, Eli Lilly, conduct studies on larger animals using dosages equal to that proposed for humans.

Those results are expected soon and all indications are the drug will be considered safe enough to get the FDA's nod of approval.

Until then, Wisner Greene says another new treatment option is Evista (raloxifene), a medication known as a SERM—short for "selective estrogen receptor modulator."

Often referred to as a "designer estrogen," SERMs work on a variety of diseases "by offering the benefits of estrogen without the side effects of estrogen replacement therapy, such as increased risk of breast and uterine cancer," says Wisner Greene. In osteoporosis, Evista works much like estrogen to help ensure that bone production is not outpaced by bone loss.

Also available are drugs known as bisphosphonates—
medications such as Fosamax, Didrocal (Etidronate) and Actonel (risedronate). They work specifically to slow down bone loss. Although they can be hard on the gastrointestinal tract, a new intravenous form is being tested, with a one-time treatment offering protection for up to a year.

A third alternative is the drug Miacalcin (calcitronin), a synthetic version of a hormone made in the thyroid gland that is involved in the breaking down of old bone cells. Available as a nasal spray, it also works to reduce the rate of bone loss.

Finally, for those who wish to take a more natural approach, boosting vitamin D intake along with 1,500 mg of calcium daily is the way to go.

What can also help: Weight-bearing exercises such as brisk walking, which can increase the production of new bone.